Health Promotion Services Presentation Request Form : University Health Services : Texas State University

Requestor's Name *

Name of Organization/Class *

E-Mail *

Contact Number *

Primary Contact Number For Presentation Day *

Will the requester be present for the presentation? *

Yes

No

If no, please list the day-of contact person's name and number. *

Presentation Requested *

Becoming an Upstander: Addressing Alcohol, Drugs, and Sexual Violence on Campus

Close Your Eyes and Count to Zen: Managing Stress in College

Contraception Minute-to-Win-It

Sex, Lies, and Chocolate

Staying Healthy in College

Yes Means Yes: Getting Consent

Red Flags in Relationships

Responding to Interpersonal Violence: Addressing and Preventing Violence on Campus

Other:* Specify Below

Other

Preferred Date for Presentation *

Second Preferred Date (must be a different date than first preferred) *

Third Preferred Date (must be a different date than first and second preferred) *

Location of Program *

Time *

A.M. or P.M.?

a.m.

p.m.

Duration of Class Time *

50 minutes

1 hour

1 hour 15 minutes

1 hour 30 minutes

Expected Number of Attendees *

Do you have media equipment? *

Yes

No

Media Equipment Available

LCD (Projector)

Projection Surface

Computer

None

Is Wi-Fi Available? *

Yes

No

Special Comments: